Title: Case management in primary care for frequent users of healthcare services (Led by Quebec with partners in SK, NS & NL)
NS Research Team: Lynn Edwards, Tara Sampalli, Rick Gibson, Fred Burge

Patients who have multiple chronic conditions, requirements for mental health care and/or are vulnerable because of social determinants of health are often considered to have complex health care needs.  These patients require services from various health systems and community networks.  Often, these patients have unmet healthcare needs and may try to access different services in an uncoordinated manner that is unsuccessful for them and expensive for the health care system.  Case management (CM) is the most promising intervention to improve care integration and reduce uncoordinated use of the system.  The goal of this research is to understand what works when using CM in primary care, for which people, under what circumstances and in what ways.  This will be shared with policy makers, clinicians, patients/families, researchers, and other primary care stakeholders to improve care.

Title: Screening for Poverty And Related social determinants and intervening to improve Knowledge of and links to resources (SPARK) Study (Led by Ontario with partners in SK, MB, NS & NL)
NS Research Team: Lois Jackson, Fred Burge, Emily Marshall, Rick Gibson, Lynn Edwards, Tara Sampalli

The conditions of living in poverty lead people to experience increased sickness, disability, and negative health outcomes compared to those who are wealthy. Since poverty has such a strong effect on people’s health, it is important to collect information about it in “primary care settings”—these include hospitals, doctor’s offices, and community health centres. We are conducting a study to help doctors and other healthcare providers collect information on poverty and other social factors that impact peoples’ health (including: gender, race, sexual orientation and housing). This information will be collected through a short questionnaire that will be offered while patients wait for their medical appointment. This data will be connected to patients’ Electronic Medical Record (EMR) and will be used to link patients to services that may help them with low incomes and other social factors affecting their health. This data can also help staff in primary care settings and policymakers improve resource allocation, to help lessen preventable differences in health outcomes for patient populations.

Title: SPIDER-NET, A Structured Process Informed by Data, Evidence and Research-Network: An approach to support primary care practices in optimizing the management of patients with complex needs (Led by Ontario with partners in QC, NS, MB & AB)
NS Research Team: Mathew Grandy, Fred Burge

The Structured Process Informed by Data, Evidence and Research (SPIDER) project focuses on older patients taking many medications.  Taking multiple medications (also called polypharmacy) often means more side effects and this gets worse as people age.  Older adults are at a higher risk of side effects like confusion, dizziness and falls.  SPIDER will help family doctors and their teams deliver better care by reviewing and reducing the use of riskier drugs for selected patients in their practice.  SPIDER will improve care for older adults in our communities by reducing and improving their medication use, supporting their health and helping them reach their goals for quality of life.  It may also save the health care system money by reducing the number of times people are admitted to hospital.  SPIDER is being conducted in 5 provinces and is led by a team of pharmacists, family doctors, patients and researchers.